TAM Airlines Flight 3054
TAM Airlines Flight 3054 (JJ 3054) was an Airbus A320 airliner, registration PR-MBK, operating as a scheduled domestic passenger flight between Porto Alegre and São Paulo, Brazil, which crashed upon landing during rain in São Paulo on July 17, 2007. The twin-engined turbofan aircraft overran the runway, crossed a major thoroughfare during rush hour, crashed at high speed into a TAM Express warehouse adjacent to a filling station and exploded. There were 187 people on board: 181 passengers, 19 of them TAM employees, and 6 crew members. All passengers and crew were killed in the crash, in addition to twelve people on the ground. Globo.com, Globo G1 Noticias Retrieved July 23, 2007 At the time, Flight 3054 had the highest death toll of any aviation accident in Latin America, but was surpassed by the crash of Air France Flight 447 in 2009. It remains the deadliest accident involving an Airbus A320 anywhere in the world. Aircraft Flight 3054 was an Airbus A320-233 serial number 789, registration PR-MBK, powered by two International Aero V2527E-A5 turbofan engines. According to Flight International, the aircraft was built in February 1998 and first entered service in March flying for Grupo TACA and later in November 2003 by Pacific Airlines. The aircraft was owned by Pegasus Aviation prior to the crash, and entered into service for TAM in December 2006. As of April 20, 2007, the aircraft had flown 20,379 hours over 9,313 cycles. The aircraft was dispatched with the thrust reverser (a mechanical device to help slow the airplane down on landing) on the number 2 (right-side) engine deactivated as it had jammed. TAM said in a statement that a fault in a reverser "does not jeopardize landings." In the same statement TAM also said "no mechanical problem had been recorded on July 16 (the day before the accident)." It was reported that the plane had difficulty braking on the same runway one day prior to the fatal accident. The inactivated thrust reverser on the number 2 engine was confirmed by Airbus on July 25. Flight chronology The plane departed from Salgado Filho International Airport in Porto Alegre at 17:16 local time (20:16 UTC). It crashed upon landing at Congonhas-São Paulo International Airport in São Paulo at 18:50 local time (21:50 UTC). Crash Flight 3054 was cleared to land at Congonhas' 35L runway. Reviews by government officials of the surveillance videos showed that despite the aircraft touching down at the normal touch-down point on the runway, it did not slow down normally, crossing the far end of the runway at around 90 knots (103 mph, 162 km/h). Authorities say the plane was above normal speed O Estado de S. Paulo. Retrieved July 18, 2007. The aircraft, bearing to the left, continued off the end of the runway. The runway is elevated above the surrounding area, and the aircraft's momentum carried it over the traffic on the adjacent Avenida Washington Luís, a major thoroughfare. After clearing the road, the aircraft exploded on impact with a four-story TAM Express facility, resulting in a large fire and killing everybody on board instantly. The TAM Express building contained offices and a warehouse, and was located adjacent to a gas station. The runway had recently been resurfaced, but it did not yet have water-channeling grooves cut into it to reduce the danger of hydroplaning. Flight Data Recorder (FDR) information recovered after the crash and released by Brazilian authorities showed that immediately prior to touchdown, both thrust levers were in CL (or "climb") position, with engine power being governed by the flight computer's autothrottle system.TAM Airbus 320-200, Flight No. 3054, PR-MBK. NTSB. July 24, 2007. Retrieved on September 5, 2007. Two seconds prior to touchdown, an aural warning, "retard, retard," was issued by the flight's computer system, advising the pilots to "retard" the thrust lever to the recommended idle or reverse thrust lever position. This would disengage the aircraft's autothrottle system, with engine power then being governed directly by the thrust lever's position. At the moment of touchdown, the spoiler lever was in the "ARMED" position. According to the system logic of the A320's flight controls,A320 Flight Controls Manual. Airbus. Retrieved on September 5, 2007 in order for the spoilers to automatically deploy upon touchdown not only must the spoiler lever be in the "ARMED" position, but both thrust levers must be at or close to the "idle" position. The FDR transcript shows that immediately after the warning, the flight computer recorded the left thrust lever being retarded to the rear-most position, activating the thrust reverser on the left engine, while the right thrust lever (controlling the engine with the disabled thrust reverser) remained in the CL position. The pilots had only retarded the left engine to idle because they thought that without thrust reverser, the right engine did not need to be retarded as well. Airbus autothrust logic dictates that when one or more of the thrust levers is pulled to the idle position, the autothrust is automatically disengaged. Thus, when the pilot pulled the left engine thrust lever to idle it disconnected the autothrust system. Since the right engine thrust lever was still in the "climb" detent, the right engine accelerated to climb power while the left engine deployed its thrust reverser. The resulting asymmetric thrust condition resulted in a loss of control and a crash ensued. Moreover, the A320's spoilers did not deploy during the landing run, as the right thrust lever was above the "idle" setting required for automatic spoiler deployment. Congonhas Air safety in Brazil had been under increased scrutiny recently following the mid-air collision in September 2006 over the Amazon of Gol Transportes Aéreos Flight 1907 and an Embraer Legacy 600 (see Brazil's 2006-2007 aviation crisis). Congonhas was singled out for having safety issues relating to operations in wet weather due to its location and runway characteristics for the traffic it serves. The 35L runway at Congonhas is 1,940 metres (6,365 feet) long. Congonhas' counterpart in Rio de Janeiro, the Santos Dumont Airport, has an even shorter runway, at 1,323 metres (4,341 ft). Both airports receive the same type of traffic - ranging from small private planes to Boeing 737s and A320s. Many variables affect the landing distance of an aircraft, such as approach speed, weight and the presence of either a tailwind or a headwind. For an Airbus A320, a speed of just 20 knots higher than normal can result in as much as a 25% increase in the runway length needed to stop an aircraft. Wet weather can also significantly reduce the braking performance of aircraft, leading to an increase in the minimum runway length requirement.A320 Warsaw landing analysis Prof. Clive Leyman, City University of London. Retrieved July 18, 2007 Pilots have called Congonhas airport the "aircraft carrier," because of the runway's short length and because pilots are told to take off again and fly around if they overshoot the first 1,000 feet of runway.Latimes.com Death toll in Sao Paulo crash at 189 and could rise (Associated Press via latimes.com) 2007-07-17, Retrieved 2009-02-03 In February 2007, a Brazilian judge briefly banned flights using Fokker 100, Boeing 737-700 and Boeing 737-800 aircraft in and out of the airport. The Airbus A320 was not among the aircraft banned, due to its manufacturer-stated braking distance being shorter than those of the banned aircraft. Pilots had complained that water had been accumulating on the runway, reducing aircraft braking performance and occasionally causing planes to hydroplane. The judge claimed the runway needed to be 388 metres (1,275 ft) longer for these aircraft to operate safely. At the time, a spokeswoman from Brazil's National Civil Aviation Agency claimed "The safety conditions of the runway and the airport as a whole are adequate." TAM also objected to the decision, with a spokesman stating "If the injunction stands, it will cause total chaos," claiming over 10,000 passengers per day would be inconvenienced. The airport authorities appealed the decision, resulting in it being overturned the following day. An appeals court overruled the ban on the three types of planes, saying it was too harsh as it would have severe economic ramifications and that there were not enough safety concerns to prevent the planes from landing and taking off from the airport. "The runway was reopened because of popular pressure," Gianfranco Beting, an aviation consultant, said in a TV interview. Aftermath The airport reopened on July 19, 2007 using an alternative runway. Many flights, including all OceanAir and BRA Transportes Aéreos, were transferred to Guarulhos International Airport, the major airport in São Paulo, due to the closure of the main runway at Congonhas and the ongoing investigation of the accident. On July 20, Presidency Chief of Staff Dilma Rousseff announced plans to significantly reduce the number of flights operating at Congonhas. The plan included banning, within 60 days, all connection, stopover, charter, and international flights and the reduction in the number of private jets. The airport would only operate direct flights to certain cities in Brazil. The plan also called for a study of the expansion of São Paulo's two current airports and the construction of a third airport in the metropolitan area.Confirmed: São Paulo will have a 3rd Airport , 20 July 2007 State crime scene investigators terminated the search for remains on July 28, 2007; as of that date, 114 bodies recovered from the site had been identified by the São Paulo Medical Examiner's Office as those of passengers. Investigation The investigation was carried out by Brazil's Aeronautical Accidents Investigation and Prevention Center (Centro de Investigação e Prevenção de Acidentes Aeronáuticos, CENIPA). Data from the flight data recorder and cockpit voice recorder (CVR) were downloaded by the National Transportation Safety Board in the United States commencing July 20 and July 23 respectively. Based on preliminary data from the FDR, on July 25 Airbus cautioned A320 operators to ensure that both thrust levers are set to idle during flare. The transcript of the CVR was released on August 1. It shows that the pilots were aware of the wet runway conditions and the deactivated thrust reverser. The pilots' comments suggest that the spoilers did not deploy and that they were unable to slow the aircraft. Crew error has not been ruled out. An investigation by the Brazilian Public Safety Ministry released in November 2008 concluded that the pilots mistakenly retarded only the left engine to idle, because the right one had no thrust reverser working when in fact it was necessary to retard both engines in order for the spoilers to work. They also said that the National Civil Aviation Agency should have closed the airport on the night the plane landed because of heavy rains; that Congonhas airport authorities shared the blame because its runway had not been properly constructed with grooves to drain away excess rainwater, contributing to the crash; that the plane's manufacturer, Airbus, should have provided alarms warning the pilots that the braking system was failing; and that TAM failed to properly train its pilots, who did not act correctly in the emergency. Final Report In September 2009, more than two years after the accident, the Aeronautical Accidents Investigation and Prevention Center (CENIPA) announced the results of official investigations. The report shows that one of the thrust levers, which control engines, was in position to accelerate when it should be in idle, but it was not proved if there was mechanical or human failure as the cause of the accident.Final Report (PDF), Aeronautical Accidents Investigation and Prevention Center, October 27, 2009. The report suggests two hypotheses for the accident. In the first, there was a flaw in the power control of the plane's engines, which would have kept one of the thrust levers into acceleration, regardless of their actual position. In such circumstances, there was mechanical failure of the aircraft. In the second hypothesis, the pilot has performed a procedure different from that provided in the manual, and put the thrust lever in an irregular position, a configuration of human error for the accident. In addition to the positions of the thrust levers, the report points several factors that may have contributed to the accident, as a high volume of rain on the day, with the formation of puddles on the runway, as well as the absence of grooving. The report does not blame the length of the runway as responsible for the accident. Response After the crash, President Lula of Brazil ordered three days of national mourning. During the 2007 Pan American Games in Rio de Janeiro, the Brazilian athletes wore a black armband in remembrance of the victims. The flags of all participating countries were flown at half mast on July 18. Matches involving a Brazilian athlete or team started with a minute of silence. All matches of the Campeonato Brasileiro 2007 started with a minute of silence, while all players wore black armbands. Brazilian Formula One driver Felipe Massa had a black stripe on top of his helmet during the 2007 European Grand Prix, to commemorate the victims. Rubens Barrichello also had stripes on his helmet, and the two Red Bull Racing drivers David Coulthard and Mark Webber had small Brazilian flags on their helmets referring to the accident. More than 5,000 Brazilians marched to the crash site on July 29, 2007, blaming their government's failure to invest in airport infrastructure for the crash. Many of the protesters also demanded the ousting of President Luiz Inacio Lula da Silva. Notable passengers Among the passengers were: * Júlio Redecker (aged 51), a Brazilian Social Democracy Party federal politician, member and leader of the opposition in the Chamber of Deputies of Brazil. * Paulo Rogério Amoretty Souza (aged 61), former chairman of the football team Sport Club Internacional and attorney for Sport Club Corinthians Paulista. Dramatization Mayday (Also known as Air Crash Investigation in the UK, Australia and Asia and Air Emergency or Air Disasters in the United States) produced a one hour docudrama about the crash. The episode was entitled "Deadly Reputation". References External links ** Final Report (Archive) ** Final Report (Archive) * TAM Airlines ** Comunicados TAM (Press releases from TAM regarding the incident) ** TAM Informa (Material from TAM Airlines about the incident) * Bureau d'Enquêtes et d'Analyses pour la Sécurité de l'Aviation Civile ** Accident in São Paulo on 17 July 2007 ** Accident survenu à São Paulo le 17 juillet 2007 * Press Release - German Federal Bureau of Aircraft Accidents Investigation * * In pictures: Brazil plane crash (BBC) * Video from Congonhas airport security camera, comparing a normal landing with TAM flight 3054's landing * The World's Worst Airline - Elizabeth Spiers * Plane Crashes in Brazil * List of passengers on Flight 3054 *Photographs Category:Airliner accidents and incidents caused by weather Category:2007 in Brazil Category:Aviation accidents and incidents in 2007 Category:Airliner accidents and incidents caused by pilot error Category:Aviation accidents and incidents in Brazil Category:Airliner accidents and incidents involving runway overruns Category:TAM Airlines accidents and incidents Category:Accidents and incidents involving the Airbus A320 Category:Airliner accidents and incidents caused by weather Category:2007 in Brazil Category:Aviation accidents and incidents in 2007 Category:Airliner accidents and incidents caused by pilot error Category:Aviation accidents and incidents in Brazil Category:Airliner accidents and incidents involving runway overruns Category:TAM Airlines accidents and incidents Category:Accidents and incidents involving the Airbus A320